Interprofessional collaboration in palliative dementia care

Interprofessional collaboration (IPC) is essential for high-quality palliative care (PC) for persons with dementia. The aim of this scoping review was to identify IPC approaches in palliative dementia care and explore the elements constituting these approaches. We performed a search in PubMed, CINAHL, and PsychINFO using the Joanna Briggs Institute Reviewers' manual and PRISMA guidelines, and conducted content analysis of the included articles. In total, 28 articles were included, which described 16 IPC approaches in palliative dementia care. The content analysis revealed three overall elements of these approaches: 1) collaborative themes, 2) collaborative processes, and 3) resources facilitating collaboration. Frequently reported collaborative themes embraced pain management and providing care in the dying phase. These themes were addressed through intertwined collaborative processes including communication, coordination, assessing and monitoring, and reflecting and evaluating. To ensure optimal IPC in palliative dementia care, various resources were required, such as PC knowledge, skills to manage symptoms, skills to communicate with collaborators, and a facilitating environment. In conclusion, the identified IPC approaches in palliative dementia care involve diverse collaborating professionals who mainly manage symptoms, prepare for the dying phase and require material and immaterial resources to enable optimal IPC in palliative dementia care.

Effectiveness of guided telerehabilitation on functional performance in community-dwelling older adults: A systematic review

OBJECTIVE

To systematically review the effectiveness of guided telerehabilitation on improving functional performance in community-dwelling older adults.

DATA SOURCES

Articles published in PubMed, Cochrane Library and Embase (Ovid) from 01 January 2010 up to 17 October 2023.

REVIEW METHODS

Included studies had (1) a randomised controlled trial design, (2) an average population age of 65 years or older, (3) a home-based setting and (4) evaluated the effectiveness of functional performance outcome measures. The intervention was considered telerehabilitation when guided by a healthcare professional using video, audio and/or text communication technologies with a minimum frequency of once per week. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement guideline was followed. Methodological quality was appraised using the revised Cochrane Risk of Bias tool.

RESULTS

A total of 26 randomised controlled trials were included. Telerehabilitation had superior (N = 15), non-superior (N = 16) or non-inferior (N = 11) effectiveness for improving functional performance outcome measures compared to control interventions. No studies found the control intervention to be superior over telerehabilitation. Between study differences in intervention characteristics contributed to significant clinical heterogeneity. Five studies were found to present an overall 'low' risk of bias, 12 studies to present 'some' risk of bias and 9 studies to present an overall 'high' risk of bias.

CONCLUSION

The findings suggest that telerehabilitation could be a promising alternative to in-person rehabilitation for improving functional performance in community-dwelling older adults. Additional well-designed studies with minimised bias are needed for a better understanding of effective telerehabilitation intervention strategies.

Posttraumatic stress disorder in people with dementia: study protocol

Background: Posttraumatic stress disorder (PTSD) is considered an independent risk factor for dementia. Despite the (clinical) evidence that PTSD is associated with neuropsychiatric symptoms in people with dementia, studies on its prevalence and clinical manifestation are limited, and their quality is affected by the lack of a structured method to diagnose PTSD in this population. The primary aim of the current study is to validate the 'TRAuma and DEmentia' interview as a diagnostic tool for PTSD in people with dementia and to test feasibility of EMDR treatment for people with PTSD and dementia.Methods: This prospective multi-centre study is divided into two parts. In study A, 90 participants with dementia will be included to test the criterion validity, inter-rater reliability and feasibility of the 'TRAuma and DEmentia' interview. In study B, 29 participants with dementia and PTSD will receive eye movement desensitisation and reprocessing therapy by a trained psychologist, and 29 participants with dementia and PTSD will be placed on the waiting list control group.Conclusion: This study aims to improve the diagnostic process of PTSD and to assess the effects of eye movement desensitisation and reprocessing treatment in people with dementia living in Dutch care facilities.Trial registration: NL70479.068.20 / METC 20-063 / OSF registration: https://doi.org/10.17605/OSF.IO/AKW4F.

Malnutrition risk and oropharyngeal dysphagia in the chronic post-stroke phase

Background

Oropharyngeal dysphagia (OD) and malnutrition are associated with poor clinical outcomes after stroke. The present study evaluated (1) malnutrition risk and OD-related characteristics in patients with chronic post-stroke OD, and (2) the relationship between on the one hand OD severity and on the other hand functional oral intake and dysphagia-specific quality of life.

Methods

A cross-sectional study was conducted in a Dutch interdisciplinary outpatient clinic for OD. The standardized examination protocol comprised: clinical ear, nose, and throat examination, body mass index, the short nutritional assessment questionnaire (SNAQ), a standardized fiberoptic endoscopic evaluation of swallowing (FEES), the functional oral intake scale (FOIS), and the MD Anderson dysphagia inventory (MDADI).

Results

Forty-two consecutive patients with chronic post-stroke OD were included. Mean (±SD) age and BMI of the population were 69.1 (±8.7) years and 26.8 (±4.1) kg/m2 respectively. Seventeen (40.4%) patients presented a moderate to high risk of malnutrition (SNAQ score≥2). The FEES examination showed moderate to severe OD in 28 (66.7%) patients. The severity of OD was significantly related to the FOIS score but not to the MDADI scores.

Conclusion

In this specific sample of referred stroke patients, moderate to severe OD and moderate to high risk of malnutrition were common. Despite the use of clinical practice guidelines on stroke and a normal nutritional status at first sight, repeated screening for malnutrition and monitoring the severity and management of OD remain important elements in the care of patients with chronic post-stroke OD.

Post-acute COVID-19 geriatric rehabilitation : A European perspective

Coronavirus disease 2019 (COVID-19) poses a threat to the health and independence of older people in particular. In this article we elaborate on the content and importance of post-acute COVID-19 geriatric rehabilitation from a European perspective. We explain the geriatric rehabilitation paradox and how this can and should be solved. We also present what post-acute COVID-19 geriatric rehabilitation should entail. This might not only help us to develop better geriatric rehabilitation services, but it should also inform pandemic preparedness in the future.

Dysphagia, Fear of Choking and Preventive Measures in Patients with Huntington's Disease: The Perspectives of Patients and Caregivers in Long-Term Care

OBJECTIVES

To explore the prevalence of dysphagia and fear of choking in patients with Huntington's disease (HD) as well as preventive measures, both those applied and those not included in managing dysphagia. Also, to investigate related problems encountered by their formal and informal caregivers.

DESIGN

A multi-center observational cross-sectional study.

SETTING AND PARTICIPANTS

158 HD patients, recruited from six Dutch nursing homes specialized in HD, and their formal and informal caregivers.

MEASUREMENTS

Patients were assessed by means of questionnaires enquiring about dysphagia, fear of choking and measures to manage dysphagia. Also, questionnaires were administered about awareness of dysphagia symptoms, cognition and anxiety. Because we expected individuals with greater care dependency to have a higher severity of dysphagia, we distinguished between a care-independent and a care-dependent group of HD patients.

RESULTS

In the total group, 90.5% of HD patients had one or more dysphagia symptoms. The prevalence of FoC in HD patients and the formal and informal caregivers' fears about choking in HD patients was 45.7%, 19.0% and 59.5%, respectively, for care-independent patients and 58.7%, 50.1% and 77.5% for care-dependent patients. The score on the Huntington's Disease Dysphagia Scale was a predictor for fear of FoC in care-independent patients. Speech-language therapy, supervision during eating and drinking and adaptation of food and drink consistency were the most frequently applied measures to manage dysphagia, a combination was used in most HD patients.

CONCLUSIONS

In HD patients, the prevalence of dysphagia is high and fear of choking is common among both patients and caregivers. A more severe degree of dysphagia is a predictor of FoC in care-independent HD patients. A combination of measures was used to manage dysphagia in most HD patients.

The effect of a hand hygiene intervention on infections in residents of nursing homes: a cluster randomized controlled trial

BACKGROUND

The primary goal of hand hygiene is to reduce infectious disease rates. We examined if a nursing home's participation in a hand hygiene intervention resulted in residents having fewer healthcare associated infections (HAIs) when compared to nursing homes without the hand hygiene intervention.

METHODS

This study is a part of a cluster randomized controlled trial (RCT) in 33 nursing homes to improve hand hygiene (HANDSOME). The incidence of five illnesses was followed over 13 months: gastroenteritis, influenza-like illness, pneumonia, urinary tract infections and infections from methicillin-resistant Staphylococcus aureus (MRSA). Incidence rates per study arm were reported for baseline (October-December 2016) and two follow-up periods (January-April 2017, May-October 2017). HAI rates were compared in a Poisson multilevel analysis, correcting for baseline differences (the baseline infection incidence and the size of the nursing home), clustering of observations within nursing homes, and period in the study.

RESULTS

There was statistically significantly more gastroenteritis (p < 0.001) and statistically significantly less influenza-like illness (p < 0.01) in the intervention arm when compared to the control arm. There were no statistically significant differences or pneumonia, urinary tract infections, and MRSA infections in the intervention arm when compared to the control arm. In a sensitivity analysis, gastroenteritis was no longer statistically significantly higher in the intervention arm (p = 0.92).

CONCLUSIONS

As in comparable studies, we could not conclusively demonstrate the effectiveness of an HH intervention in reducing HAIs among residents of nursing homes, despite the use of clearly defined outcome measures, a standardized reporting instrument, and directly observed HH in a multicenter cluster RCT. Trial registration Netherlands Trial Register, trial NL6049 (NTR6188). Registered October 25, 2016, https://www.trialregister.nl/trial/6049 .

Pan-European Study on Functional and Medical Recovery and Geriatric Rehabilitation Services of Post-COVID-19 Patients: Protocol of the EU-COGER Study

OBJECTIVES

There is insufficient knowledge about the functional and medical recovery of older people infected with SARS-CoV-2. This study aims to gain insight into the course of functional and medical recovery of persons who receive geriatric rehabilitation (GR) following SARS-CoV-2 infection across Europe. Special attention will be paid to the recovery of activities of daily living (ADL) and to the GR services offered to these patients.

DESIGN

A multi-center observational cohort study.

SETTING AND PARTICIPANTS

This study will include several European countries (EuGMS member states) each providing at least 52 comparable routine datasets (core dataset) of persons recovering from a SARS-CoV-2 infection and receiving geriatric rehabilitation. The routine data will be anonymously collected in an online CASTOR database. The ethical regulations of each participating country will be followed.

PRIMARY OUTCOME

ADL functioning.

SECONDARY OUTCOMES

length of stay, discharge destination, hospital readmission and mortality. Other variables that will be collected are quality of life, treatment modalities, complications, cognition, frailty, mood/anxiety, BMI, nutrition and pain. All variables will be reported at admission and compared with follow-up scores (discharge, 6 weeks and 6 months follow-up).

CONCLUSION

This study will explore the effect of geriatric rehabilitation on post-COVID-19 patients, especially on ADL recovery, and the variety of geriatric rehabilitation services across Europe. Information from this study may help improve recovery of older persons infected with SARS-CoV-2 and improve geriatric rehabilitation services in the ongoing COVID-19 pandemic.

Malnutrition Prevalence Rates among Dutch Nursing Home Residents: What Has Changed over One Decade? A Comparison of the Years 2009, 2013 and 2018

OBJECTIVES

To assess changes in prevalence of malnutrition and its associated factors among people living in Dutch nursing homes in 2009, 2013 and 2018.

DESIGN

Secondary data analysis of the International Prevalence Measurement of Care Quality (LPZ) study.

SETTING

Dutch nursing homes.

PARTICIPANTS

Residents living at a psychogeriatric or somatic ward in Dutch nursing homes in 2009, 2013 or 2018.

MEASUREMENTS

weight and height, unintentional weight loss over the last month and last six months, age, sex, length of stay up to the measurement day, care dependency, and the presence of various diseases (dementia, diabetes mellitus, stroke, diseases of the respiratory system, respiratory diseases and pressure ulcers).

RESULTS

In total, 14,317 residents were included in this study with a mean age of 82.2, 70.9 female and 66.8% was living on a psychogeriatric ward. Results of this study show relative stability in background characteristics of the nursing home population over the last decade. In the total sample, 16.7% was malnourished and these percentages were 16.6% in 2009, 17.5% in 2013 and 16.3% in 2018. Multiple binary logistic regression analyses revealed having a pressure ulcer, female sex and living on a psychogeriatric department to be positively associated and having diabetes mellitus to be negatively associated with malnutrition throughout the years. These associations were strong and similar across years.

CONCLUSION

Even though much attention has been paid to prevent malnutrition in Dutch nursing homes over the last decades, results show a relatively stable malnutrition prevalence rate of around 16%. This leads to the question if nursing staff is able to sufficiently recognize residents with (a risk of) malnutrition, and if they are aware of interventions they could perform to decrease this rate.

Nurses' needs when collaborating with other healthcare professionals in palliative dementia care

Adequate interprofessional collaboration is essential to provide high quality palliative dementia care across different settings. Within interprofessional collaboration, nurses are the frontline healthcare professionals (HCPs), who interact closely with people with dementia, their loved ones, and other HCPs. A survey was conducted to explore the needs of nurses regarding interprofessional collaboration in home care (HC) organisations, nursing homes (NHs) and during NH admissions. The survey identified the perceived quality of and preferred needs regarding interprofessional collaboration. In total, 384 participants (53.9% home care nurses) completed the survey. The most frequently reported collaboration needs in HC organisations and NH were optimal communication content e.g. information transfer and short communication lines (being able to easily contact other disciplines), and coordination e.g. one contact person, and clear task division and responsibilities). During NH admissions, it was important to create transparency about agreements concerning end-of-life wishes, optimize nurse-to-nurse handover during NH admissions (through performing visits prior to admissions, and receiving practical information on how to guide relatives), and improve coordination (e.g. one contact person). In conclusion, the key collaboration needs were organising central coordination, establishing optimal communication, and creating transparency on end-of-life care agreements.

[Older people with complex, combined care needs: the need for tailored collaborative care]

Older patients with combined psychiatric, physical and cognitive health problems - patients who need double care - benefit from integrated medical and psychiatric care. The characteristics of these patients, as well as the problems that may exist in offering them adequate integrated care, are illustrated on the basis of a case description. Improvement of existing regional arrangements, premised on a collaborative care model, and involving hospital care, mental health services, nursing home care and community care services, is recommended. In settings that offer 24 hour long-term residential care and treatment, the expertise of mental health services and nursing homes must be structurally combined.

The Living Lab In Ageing and Long-Term Care: A Sustainable Model for Translational Research Improving Quality of Life, Quality of Care and Quality of Work

There is a strong need in long-term care for scientific research, so older people and their families, health care professionals, policy makers, and educators can benefit from new advancements and best available evidence in every day care practice. This paper presents the model of a sustainable and successful interdisciplinary collaboration between scientists, care providers and educators in long-term care: the "Living Lab in Ageing and Long-Term Care" by Maastricht University in the Netherlands. Its mission is to contribute with scientific research to improving i) quality of life of older people and their families; ii) quality of care and iii) quality of work of those working in long-term care. Key working mechanisms are the Linking Pins and interdisciplinary partnership using a team science approach, with great scientific and societal impact. A blueprint for the model is discussed, describing its business model and challenges in getting the model operational and sustainable are discussed.

[Research agenda oral care for older people in the Netherlands and Flanders (Belgium)]

Oral care for older people is an underexposed topic in dentistry as well as in general healthcare, while oral care professionals are increasingly confronted with frail and multimorbid older people with complex care needs. The research agenda 'Oral care for the elderly' was developed to encourage the collaboration of researchers in the Netherlands and Flanders (Belgium) to do more research in this area and in this way, to achieve an expansion and implementation of knowledge. This will make possible the provision of a socially responsible and robust basis for sustainable oral care for frail older people. The focus of the agenda is on 3 themes, namely oral health and oral function for older people; multi/interdisciplinary collaboration within primary care and the costs, benefits and long-term effect(s) of oral care throughout the entire course of life. This article provides an overview of this research agenda and the way in which it has been established.

[Towards proactive and personalised care for the elderly]

The Netherlands, like other Western countries, shows an obvious demography of aging, which is associated with many challenges. People age differently, after all. Some remain vital until very old age, while others become frail and disabled much earlier in life. Because of the indicated demographic trend, morbidity is expected to increase and with it, the number of older people needing care. 'Aging in place' has become a central phenomenon in healthcare policies. This means that older people should be empowered to lead a meaningful life in their own living environment as long as possible, even when they are frail and care dependent. Therefore, in the future, most care for older people will actually occur at home. This article aims to present a meaningful care model for the older people. Starting from the 'definition discussion' about frailty and a revaluation of the concept of' resilience, a basis will be provided for a sustainable, proactive and personalised elderly care, close to the living environment of older people, in which dentists and other oral health professionals play an important role as well.

Low Levels of Branched Chain Amino Acids, Eicosapentaenoic Acid and Micronutrients Are Associated with Low Muscle Mass, Strength and Function in Community-Dwelling Older Adults

BACKGROUND

Sarcopenia, the age-related decrease in muscle mass and function can result in adverse health outcomes and subsequent loss of independence. Inadequate nutrition is an important contributor to the aetiology of sarcopenia, and dietary strategies are studied to prevent or delay this geriatric syndrome.

OBJECTIVE

The present study investigated whether there is an association between biochemical nutrient status markers, muscle parameters and sarcopenia in community-dwelling older adults.

DESIGN

Data from the cross-sectional Maastricht Sarcopenia study (MaSS) were used, in which skeletal muscle index (SMI), 4 meter gait speed, 5 times chair stand and handgrip strength were assessed among older adults (n=227). Sarcopenia was defined following the algorithm of the European Working Group on Sarcopenia in Older People. Fasted blood samples were analyses on amino acids levels, RBC phospholipid profile, 25-hydroxyvitamin D (25(OH)D), α-tocopherol, magnesium and homocysteine were determined in fasted blood levels. Generalized linear modelling and logistic regression were used for data analysis.

RESULTS

Lower blood levels of essential amino acids (EAA), total branched-chain amino acids (BCAA) and leucine were associated with lower SMI (P<0.001), strength (P<0.001) and longer time to complete the chair stand (P<0.05), whereas no association was found for total amino acids (TAA). Lower levels of eicosapentaenoic acid (EPA), 25(OH)D and homocysteine were associated with lower muscle parameter values (P<0.05). No significant associations were found for SFA, MUFA, PUFA, n-3 and n-6 fatty acids, docosahexaenoic acid (DHA), α-tocopherol-cholesterol ratio and magnesium. Sarcopenia was more frequent among those with lower levels of leucine, BCAA, EAA, EPA, 25(OH)D and higher levels of homocysteine (P<0.05). Age and BMI were identified as relevant covariates. A robust association was only found for lower gait speed and lower 25(OH)D levels.

CONCLUSION

Compromised muscle parameters are associated with low blood values of specific amino acids, fatty acids, vitamin D and high homocysteine.

Sarcopenia Is Related to Mortality in the Acutely Hospitalized Geriatric Patient

BACKGROUND

Sarcopenia is defined as low skeletal muscle mass with poor physical performance, representing a strong prognostic factor for mortality in older people. Although highly prevalent in hospitalized geriatric patients, it is unknown whether sarcopenia can also predict mortality in these patients.

OBJECTIVE

To determine the association between sarcopenia according the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP), International Working Group on Sarcopenia (IWGS), Special Interest Group of Sarcopenia, Cachexia and Wasting Disorders (SIG) and Foundation for the National Institutes of Health (FNIH) and 2-year mortality in acutely hospitalized geriatric patients.

DESIGN

81 patients (84±5 y) admitted to the acute geriatric ward participated in this study. Body composition assessment (bio-impedance, Maltron Bioscan 920-II) and physical performance tests were performed, and mortality information was retrieved through patient files.

RESULTS

Prevalence rates of sarcopenia were 51% (EWGSOP), 75% (IWGS), 69% (SIG), and 27% (FNIH). Based on Cox proportional hazard ratio (HR) analysis, 2-year mortality was significantly higher in sarcopenic patients versus non-sarcopenic patients when using the EWGSOP (2-y: HR 4.310; CI-95%:2.092-8.850; P<0.001) and FNIH criteria (2-y: HR 3.571; CI-95%:1.901-6.711; P<0.001). Skeletal muscle mass index, fat mass index, body mass index, phase angle and gait speed were significantly lower in the geriatric patients who deceased after 2 years versus those who were still alive. Cox proportional HR analyses showed that higher phase angle (HR 0.678; CI-95%:0.531- 0.864; P=0.002) and higher fat mass index (HR 0.839; CI-95%:0.758-0.928; P=0.001) significantly reduced 2-y mortality probability. Combining sarcopenia criteria and separate patient characteristics finally resulted in a model in which HRs for sarcopenia (EWGSOP and FNIH) as well as phase angle significantly predicted mortality probability.

CONCLUSION

Sarcopenia is prevalent in acutely hospitalized geriatric patients and is associated with significantly higher 2-year mortality according the EWGSOP and FNIH criteria.

The oral health condition and treatment needs assessment of nursing home residents in Flanders (Belgium)

OBJECTIVES

A study was conducted of nursing home residents with limited access to regular oral health care services to evaluate their oral health status, to perform an assessment of the need for oral treatment and to determine the possible predicting value of age, gender, care dependency and income level on their oral health status and treatment needs.

MATERIALS AND METHODS

Three experienced dentists collected clinical oral health data with a mobile dental unit in 23 nursing homes. Socio-demographic data were extracted from the residents' records in the nursing home. Besides the descriptive and bivariate analysis, a general linear mixed model analysis was also performed with the nursing home as random effect.

RESULTS

The study sample consisted of 1,226 residents with a mean age of 83.9 years, of which 41.9% were edentulous. The mean D₃MFt in the dentate group was 24.5 and 77% needed extractions or fillings. In the group of residents wearing removable dentures, 36.9% needed repair, rebasing or renewal of the denture. The mixed model analysis demonstrated that with each year a resident gets older, the oral health outcomes get worse and that men have worse oral health and higher treatment needs than women. However, the level of income and care dependency had a less extensive role in predicting the oral health outcomes.

CONCLUSIONS

The nursing home residents presented a poor overall oral health status and high dental and prosthetic treatment needs. Gender and age were important predicting variables for the oral health outcomes.

Well-being of nursing staff on specialized units for older patients with combined care needs

WHAT IS ALREADY KNOWN ABOUT THE SUBJECT

Working in long-term care is seen as a stressful, physically and mentally demanding occupation, and thus, nursing staff are at risk for work and stress-related diseases. In older patients, psychiatric illnesses often occur in combination with physical illnesses, requiring nursing care that is specific to these combined care needs. The impact of caring for these patients on the mental well-being of nurses is unknown.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

Nursing staff working on specialized units for patients with combined care needs experience high levels of self-efficacy in combination with strong feelings of self-rated competence. Although levels of burnout are relatively low, mental healthcare nursing staff is more at risk for burnout when working in specialized settings for patients with combined care needs than nursing home staff working in specialized settings for these patients. Nursing staff characteristics, such as years of working experience and age, seem more important in relation to staff well-being than patient characteristics in specialized settings for combined care needs.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Staff well-being might benefit from specializing care, so that patients with similar care needs are placed together and care is focused. The presence of specialized care units for older patients with combined care needs can allow for both targeted and focused allocation of nursing staff to these units and provision of specific training.

ABSTRACT

Introduction In older patients, psychiatric illnesses frequently exist in tandem with physical illnesses, requiring nursing care that is specific to these combined care needs. The impact of caring for these patients on the mental well-being of nursing staff is unknown.

AIM

To investigate whether care characteristics of patients with combined care needs are related to the mental well-being of nursing staff.

METHOD

Well-being of nursing staff was studied within a larger exploratory observational cross-sectional study that examined the differences and similarities of specialized combined care units in Dutch mental healthcare and nursing home settings.

RESULTS

Nursing staff across settings, with more than 5 years of work experience, felt competent in caring for patients with combined care needs. No significant effects of care characteristics of patients with combined care needs on the work-related well-being of nursing staff were shown. Both mental health nursing staff and older employees, however, were found to be more at risk for burnout.

IMPLICATIONS/CONCLUSION

Staff well-being might benefit from placing patients with combined care needs together, so care is focused. The presence of specialized care units can allow for both targeted and focused allocation of nursing staff to these units and provision of specific training.

Muscle, Health and Costs: A Glance at their Relationship

OBJECTIVE

To assess the association between muscle parameters (mass, strength, physical performance) and activities of daily living (ADL), quality of life (QoL), and health care costs.

DESIGN

Cross-sectional Maastricht Sarcopenia Study (MaSS).

SETTING

Community-dwelling, assisted-living, residential living facility.

PARTICIPANTS

227 adults aged 65 and older.

MEASUREMENTS

Muscle mass, hand grip strength and physical performance were assessed by bio-electrical impedance, JAMAR dynamometer and the Short Physical Performance Battery, respectively. Health outcomes were measured by the Groningen Activity Restriction Scale (disability in ADL) and the EQ-5D-5L (QoL). Health care costs were calculated based on health care use in the past three months.

RESULTS

Muscle strength and physical performance showed a strong correlation with ADL, QoL, and health care costs (P<.01); for muscle mass no significant correlations were observed. Regression analyses showed that higher gait speed (OR 0.06, 95%CI 0.01-0.55) was associated with a lower probability of ADL disability. Furthermore, slower chair stand (OR 1.23, 95%CI 1.08-1.42), and more comorbidities (OR 1.58, 95%CI 1.23-2.02) were explanatory factors for higher ADL disability. Explanatory factors for QoL and costs were: more disability in ADL (OR 1.26, 95%CI 1.12-1.41 for QoL; B = 0.09, P<.01 for costs) and more comorbidities (OR 1.44, 95%CI 1.14-1.82 for QoL; B = 0.35, P<.01 for costs).

CONCLUSION

Lower gait speed and chair stand were potential drivers of disability in ADL. Disability in ADL and comorbidities were associated with QoL and health care costs in community-dwelling older adults. Improving physical performance may be a valuable target for future intervention and research to impact health burden and costs.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management

OBJECTIVES

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR).

METHODS

To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process.

RECOMMENDATIONS

We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Association between Oropharyngeal Dysphagia and Malnutrition in Dutch Nursing Home Residents: Results of the National Prevalence Measurement of Quality of Care

OBJECTIVES

Nursing home residents often suffer from multi-morbidities and geriatric syndromes leading to lower quality of life or mortality. Oropharyngeal dysphagia (OD) and malnutrition are profound conditions in this complex profile of multi-morbidities and are associated with deprived mental -and physical health status, e.g. aspiration pneumonia or dehydration. This study aimed to assess the association between OD and malnutrition in Dutch nursing home residents.

DESIGN

Data for this cross-sectional study were obtained from the annual National Prevalence Measurement of Quality of Care (LPZ).

SETTING

The National Prevalence Measurement of Quality of Care was conducted in Nursing Homes in The Netherlands.

PARTICIPANTS

Participants were nursing home residents age 65 or older and admitted to psychogeriatric- or somatic wards.

MEASUREMENTS

The measurements were taken by trained nurses from the participating nursing homes. Anthropometric measurements and unintended weight loss (%) were assessed to determine nutritional status (malnutrition). OD was assessed by means of a standardized questionnaire assessing clinically relevant symptoms of OD such as swallowing problems or sneezing/coughing while swallowing. Cox regression was applied to assess the association between malnutrition and clinically relevant symptoms of OD in older Dutch nursing home residents.

RESULTS

Approximately 12% of the residents suffered from swallowing problems and 7% sneezed/coughed while swallowing liquids or solid foods. Approximately 10% of the residents was malnourished. Residents with OD symptoms were more often malnourished compared to residents without OD symptoms. Approximately 17% of the problematic swallowers were concurrently malnourished. Increased risk for malnutrition was found in residents suffering from swallowing problems (PR 1.5, 95%CI 1.2-1.9), as well as in residents that sneezed/coughed while swallowing (PR 1.3, 95%CI 1.0-1.7). Stratification based on wards revealed that problematic swallowers from somatic wards were at a high risk of malnutrition (PR 1.9, 95%CI 1.3-2.8).

CONCLUSION

Clinically relevant symptoms of oropharyngeal dysphagia, such as swallowing problems and sneezing/coughing while swallowing are associated with increased risk of malnutrition in psychogeriatric and somatic Dutch nursing home residents.

Dysphagia in Hospitalized Older Patients: Associated Factors and Nutritional Interventions

OBJECTIVES

To (1) assess the association between dysphagia and malnutrition as well as other related factors and (2) investigate the nutritional interventions that are initiated in dysphagic older patients.

DESIGN

Cross-sectional, multi-center point prevalence measurement.

SETTING

53 Austrian hospitals.

PARTICIPANTS

3174 hospitalized patients, 65 years or older.

MEASUREMENTS

A standardized and tested questionnaire was used for the data collection, which was based on both inspections of the patients and information documented in the patient chart. Medical diagnoses were assessed by referring to the International Classification of Diseases. Dysphagia was measured by asking the patient a dichotomous question. Several other data points were collected including: gender, age, number of diseases, malnutrition, care dependency scale (CDS) score and dependency during activities of daily living (ADL). To investigate the associations between dysphagia and malnutrition and other associated factors, cross tabulation, chi-squared test, t-test and Mann-Whitney U test were used.

RESULTS

The prevalence of dysphagia among these patients was 7.6%. Dysphagia and malnutrition were significantly associated (< 0.001). Patients with dysphagia had statistically significant lower BMI values (p = 0.01), more medical diagnoses (p = 0.003) and were more care dependent (p < 0.001) than patients who did not suffer from dysphagia. The frequency of underlying respiratory diseases, dementia, nervous system disorders and cerebrovascular accidents also differed significantly between dysphagic and non-dysphagic patients. The following nutritional interventions were most frequently initiated in patients with dysphagia: provision of texture-modified food/fluid (32.2%), referral to a dietitian (31.4%), provision of an energy- and/or protein-enriched diet (27.3%), monitoring of nutritional intake (21.5%), enteral nutrition (19.4%) and provision of energy-enriched snacks (15.7%). 24% of patients received no nutritional interventions.

CONCLUSION

This study demonstrates that a very strong association exists between dysphagia and malnutrition as well as high levels of care dependency and dependency in activities of daily living. Nearly one-quarter of the patients did not receive any nutritional intervention. Therefore, a potential for the improvement of nutritional therapy in older dysphagic hospitalized patients still exists.

Dentists' opinions on knowledge, attitudes and barriers in providing oral health care to older people living independently in the Netherlands and Flanders (Belgium)

Objectives

The aim of this study was to investigate how dentists in the Netherlands and Flanders assessed their knowledge on oral health care to older people, what their attitude was and what barriers they experienced in rendering care to older people.

Methods

The survey data was collected from a random sample of Dutch and Flemish dentists. Five hundred ninety-five dentists (37%) of the Dutch sample and 494 dentists of the Flemish sample (41%) completed the online questionnaire. Dentists were asked to respond to 15 Likert type items, representing opinions on provision of oral health care to older people and to give information about the number of older patients treated and about some profession-specific and personal characteristics.

Results

The average number of patients treated per week was nearly twice as high in the Netherlands as in Flanders. Nevertheless, differences of opinions between dentists in the Netherlands and Flanders were relatively limited.

Conclusions

This survey shows that in particular the actual number of older patients treated appears to be related with differences of opinions between Dutch and Flemish dentists about oral health care provided to (vulnerable) older people who live at home.

[Detection and prevention in later life: risk profiles for physical, psychological, social and environmental frailty.]

In order to provide proactive care and support for older people attention is needed for the prevention of frailty among older adults. Subsequently, accurate case finding of those who are more at risk of becoming frail is crucial to undertake specific preventive actions. This study investigates frailty and risk profiles of frailty among older people in order to support proactive detection. Hereby, frailty is conceived not only as a physical problem, but also refers to emotional, social, and environmental hazards. Using data generated from the Belgian Ageing Studies (N = 21,664 home-dwelling older people), a multinomial logistic regression model was tested which included socio-demographic and socio-economic indicators as well as the four dimensions of frailty (physical, social, psychological and environmental). Findings indicate that for both men and women having moved in the previous 10 years and having a lower household income are risk factors of becoming multidimensional frail. However, studying the different frailty domains, several risk profiles arise (e. g. marital status is important for psychological frailty), and gender-specific risk groups are detected (e. g. non-married men). This paper elaborates on practical implications and formulates a number of future research recommendations to tackle frailty in an ageing society.

The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs

PURPOSE

The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia.

METHODS

A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z.

RESULTS

In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice.

CONCLUSIONS

The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

Efficacy of a Disease-Specific Nutritional Support for Pressure Ulcer Healing: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review was to summarize the evidence on the efficacy of high-calorie, high-protein nutritional formula enriched with arginine, zinc, and antioxidants (disease-specific support) in patients with pressure ulcers (PUs).

METHODS

Randomized controlled trials in English published from January 1997 until October 2015 were searched for in electronic databases (EMBASE, Medline, PubMed, and CINAHL). Studies comparing a disease-specific nutritional support (oral supplements or tube feeding) to a control nutritional intervention enabling the satisfaction of energy requirements regardless of the use of high-calorie formula or placebo or no support for at least 4 weeks were considered eligible. Study outcomes were the percentage of change in PU area, complete healing and reduction in the PU area ≥40% at 8 weeks, and the percentage of change in area at 4 weeks.

RESULTS

A total of 3 studies could be included in the meta-analysis. Compared with control interventions, formulas enriched with arginine, zinc and antioxidants resulted in significantly higher reduction in ulcer area (-15.7% [95%CI, -29.9, -1.5]; P=0.030; I2=58.6%) and a higher proportion of participants having a 40% or greater reduction in PU size (OR=1.72 [95%CI, 1.04, 2.84]; P=0.033; I2=0.0%) at 8 weeks. A nearly significant difference in complete healing at 8 weeks (OR=1.72 [95%CI, 0.86, 3.45]; P=0.127; I2=0.0%) and the percentage of change in the area at 4 weeks (-7.1% [95%CI, -17.4, 3.3]; P=0.180; I2=0.0%) was also observed.

CONCLUSIONS

This systematic review shows that the use of formulas enriched with arginine, zinc and antioxidants as oral supplements and tube feeds for at least 8 weeks are associated with improved PU healing compared with standard formulas.

Impact of Different Diagnostic Criteria on the Prevalence of Sarcopenia in an Acute Care Geriatric Ward

BACKGROUND

Sarcopenia is probably an important causal factor for functional decline in acutely ill hospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks of diagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia.

OBJECTIVES

In this study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatric patients admitted to an acute care hospital.

DESIGN

Cross sectional study design.

SETTING

A geriatric ward of a large Dutch hospital.

PARTICIPANTS

Geriatric patients.

MEASUREMENTS

Skeletal muscle mass measured using bio impedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalence was investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopenia in Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society of Sarcopenia, Cachexia and Wasting Disorders.

RESULTS

85 geriatric patients were included (61 women). Applying the 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively 26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a low gait speed.

CONCLUSIONS

Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although the prevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discover which criteria of sarcopenia can predict best adverse outcomes.

Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review

BACKGROUND

The objective of this study is to identify and review screening tools for frailty in older adults admitted to inpatient hospital care with respect to their validity, reliability and feasibility.

METHODS

Studies were identified through systematically searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and PsycINFO and screening reference lists till June 2014. Papers dealing with screening tools aimed at identifying frail older patients in in-hospital care, and including information about validity, reliability or feasibility, were included in the review. The quality of the included studies was critically appraised via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS).

RESULTS

From the originally identified 2001 studies 32 studies met the inclusion criteria, in which 16 screening tools were presented. The screening tools showed different characteristics with respect to the number of items, the method of administration and the domains included. The most frequently studied tools with respect to predictive validity were the Identification Seniors At Risk (ISAR) and Triage Risk Stratification Tool (TRST). Studies retrieved poorer information about reliability and feasibility. Overall sensitivity was fairly good. The ISAR, ISAR-HP (Identification Seniors At Risk Hospitalized Patients) and Multidimensional Prognostic Index (MPI) generally had the best sensitivity.

CONCLUSIONS

Many screening tools are available for daily practice. These tools to identify frail older patients in inpatient hospital care could be useful. For no tool, however, is clear evidence available yet regarding validity, reliability and feasibility. The overall sensitivity of the included screening tools was fairly good, whereas information on reliability and feasibility was lacking for most tools. In future research more attention should be given to the latter items.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study

OBJECTIVES

To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists.

DESIGN AND SETTING

15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed.

RESULTS

After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history.

CONCLUSION

Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

[Heart failure in nursing home residents]

OBJECTIVE

To determine the prevalence of heart failure (HF) in nursing home residents and to gain insight into the clinical characteristics of residents with heart failure.

DESIGN

Multi-centre, observational, cross-sectional study.

METHOD

501 nursing home residents aged 65 years and over, in a department for chronic somatic diseases or a psychogeriatric department, participated in this study. The diagnosis of HF and the related characteristics were based on data collected from clinical examinations for heart failure (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. A panel of two cardiologists and an internist-geriatrician made the final diagnosis of HF.

RESULTS

The prevalence of HF in nursing home residents was 33%. Dyspnoea, oedema and a history of cardiac disease were more common in residents with heart failure. Diabetes mellitus and chronic obstructive pulmonary disease also appeared to be more prevalent in this group. In 54% of the residents with HF, the diagnosis had not previously been made. Diagnosis of HF was not confirmed by the expert panel in 31% of residents with a history of HF.

CONCLUSION

Heart failure does indeed appear to be very prevalent in nursing home residents. Heart failure had not been previously diagnosed in many cases but also a previous diagnosis of heart failure could be disproved in many participants. It is therefore important that the diagnostic process for heart failure in nursing home residents be improved.

The Dutch Long-Term Care System in Transition: Implications for Municipalities

INTRODUCTION

The aim of this study is to examine the preparedness of Dutch municipalities (in terms of system readiness for innovation) for the challenges resulting from their new responsibilities under the long-term care reform of January 1, 2015.

METHODS

A qualitative research approach was used by conducting semi-structured interviews with representatives of nine Dutch municipalities responsible for the long-term care of older people in their respective municipalities.

RESULTS

Municipalities consider themselves to be largely prepared for their new responsibilities resulting from the long-term care reform. However, this perception mainly applies to practical changes (related to municipalities' organizational preparation for their new responsibilities) occurring in the short-term transition phase, not to the more long-term transformation phase.

CONCLUSION

We argue that municipalities highly underestimate the long-term challenges that lie ahead of them (such as the development of a dedicated 'participation society') and, in fact, seem to fear the uncertainty of the consequences of these challenges.

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature

BACKGROUND

Patient aggression is a longstanding problem in general hospital nursing. Staff training is recommended to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce.

AIMS

To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and to derive recommendations for further research.

DESIGN

Systematic, narrative review.

DATA SOURCES

Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies published between January 2000 and September 2011 in English, French or German were eligible of inclusion.

REVIEW METHODS

The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes i.e. attitudes, confidence, skills and knowledge were collated.

RESULTS

Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression.

CONCLUSION

Our findings corroborate findings of reviews on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Aggression needs to be tackled at an organizational level.

Malnutrition in care home residents with dementia

OBJECTIVES

To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship.

DESIGN

This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement.

SETTING

Care homes.

PARTICIPANTS

75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time.

MEASUREMENTS

A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency.

RESULTS

The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation.

CONCLUSION

The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

[Basic care in nursing homes: longitudinal presentation of care problems measured with the National Prevalence Measurement of Care Problems (LPZ)]

Since 1998, the National Prevalence Measurement of Care Problems (LPZ) has annually measured the prevalence, prevention and treatment of a number of care problems in many health care organisations. These problems include pressure ulcers, incontinence, intertrigo, malnutrition, falls and the use of restraints. This article describes trends in the prevalence of these problems during the past few years and the preventive and treatment measures taken for clients residing in psychogeriatric and/or somatic wards of nursing homes. The results show that the prevalence of these care problems has declined in general. Nevertheless, the individual interventions (preventive measures and treatment) have not really changed in recent years. It is concluded that the extra attention paid to these care problems might already have had a positive effect on their prevalence. This must be further investigated. In any case, extra follow-up steps need to be taken to bring about a further decline. The article describes which steps the project group has already taken in this respect.

[How much do patients and health professionals (really) know? The surplus value of a home visit to the patient with polypharmacy by the practice nurse, to support medication reviews in primary care]

BACKGROUND

Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse.

RESEARCH QUESTIONS

What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist?

METHOD

Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use.

RESULTS

Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%.

CONCLUSIONS

Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

Antibiotic resistance, population structure and spread of Staphylococcus aureus in nursing homes in the Euregion Meuse-Rhine

To determine the spread of Staphylococcus aureus within and between nursing home (NH) residents in the Euregion Meuse-Rhine, a cross-border region of the Netherlands and Germany, we investigated the prevalence of antibiotic resistance, genetic background and population structure of both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) isolates. A total of 245 S. aureus isolates were collected from NH residents. Susceptibility testing was performed with microbroth dilution. The genetic background was determined using spa typing, SCCmec typing, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Differences in the prevalence of resistance between the German and Dutch MSSA isolates were observed for the macrolides (15 % vs. 2 %, p = 0.003), clindamycin (15 % vs. 0 %, p = 0.003) and ciprofloxacin (34 % vs. 25 %). The macrolide and ciprofloxacin resistance varied between the NHs, while trimethoprim-sulfamethoxazole resistance was low in all residents. The MRSA prevalence was 3.5 % and <1 % among the German and Dutch NH residents, respectively (p = 0.005). The German MRSAs, isolated in 7 out of 10 NHs, belonged to ST22-MRSA-IV or ST225-MRSA-II. spa clonal complexes (spa-CCs) 015 and 002 were prevalent among the German MSSA isolates and spa-CCs 024 and 1716 were prevalent among the Dutch MSSA isolates. The antibiotic resistance of MSSA and the MRSA prevalence were significantly higher among the German NH residents. The spread of two MRSA clones was observed within and between the German NHs, but not between the Dutch and German NHs. Differences in the prevalence of resistance and the prevalence of MRSA between NHs on both sides of the border warrant the continuation of surveillance at a local level.

[Young frail elderly: assessed using the Tilburg Frailty Indicator]

BACKGROUND

Frail elderly have a higher risk of adverse outcomes, e.g., hospitalization,institutionalization, or premature death. The Tilburg Frailty Indicator (TFI) is a validated questionnaire for measuring frailty in independently living older people aged 70 years and over.

AIMS

Determining the prevalence of frailty among independently living young elderly, and examining which factors predict frailty among this target group.

METHODS

308 young elderly (58 to 64 years) completed the TFI before they visited the ambulatory health screening centre in Roosendaal. The TFI includes questions concerning physical, psychological and social frailty, and questions on possible determinants of frailty.

RESULTS

18-4% of the sample of young elderly was frail. Women scored significantly higher on psychological and social frailty. The determinants explained 37% of the frailty score. As expected,low income, an unhealthy lifestyle, multimorbidity, experiencing life events, and dissatisfaction with the living environment predicted frailty. The three frailty domains(physical, psychological, social) were affected by different determinants.

CONCLUSION

A substantial part of the young elderly in the sample turned out to be frail. The finding that the three domains of frailty are predicted by different determinants underlines the importance the importance of a broad perspective regarding the functioning of the individual older person.

[Geriatric consulting by a qualified elderly care physician in general practice]

An innovative project is presented, in which general practitioners, an elderly care physician and specialized nurses work together. The primary aim of the project was early detecting of frail community dwelling elderly and to give them adequate treatment and support, to enable them to stay in their own home situation as long as possible. The detection of frail elderly was performed by mean of the Easycare instrument. Results collected from October 2007 - July 2009 are presented in this article. The findings show that particularly elderly with symptoms of dementia have been detected. The main actions were provision of integrated psychogeriatric care according to a tailormade integral care plan and starting or extending home care. Elderly with somatic problems were seen mostly in one time consultations. The satisfaction about the care provided in the project was high, both for participating patients and professionals. In the pilot a tendency was also found towards fewer referrals to hospital (specialists) and towards a reduction of the number of acute admissions to the nursing home.

Organizing moral case deliberation Experiences in two Dutch nursing homes

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other.

Perceptions of terminally ill patients and family members regarding home and hospice as places of care at the end of life

To enable demand-based palliative care, it is important to know the perceptions of terminally ill patients and their family members regarding home and hospice as places of care at the end of life. Eight women and five men suffering from cancer and with a life expectancy of 3 months or less were interviewed. In each case one of the family members was also interviewed. Four patients spent their last phase of life at home, nine in a hospice. This paper provides further insight in the patient perspective in palliative care. The results reveal that a cohabiting partner seems an important prerequisite for terminally ill patients to stay at home. For spouses it is an obvious choice to facilitate the patients' stay at home, even when it becomes too demanding, something not discussed between spouse and patient. When sufficient care at home seems impossible and the negotiation between patients and family members results in the opinion that living at home is no longer an option, it is decided that the patient moves to a hospice. The choice for the specific setting of the patients' new residence seems to be random; one possibility is pointed out to them and seems appropriate.

Day care at green care farms: a novel way to stimulate dietary intake of community-dwelling older people with dementia?

OBJECTIVE

This study aimed to compare dietary intake of older people with dementia receiving day care at regular day care facilities (RDCFs) or at so-called green care farms (GCFs).

DESIGN AND SETTINGS

A comparative cross-sectional study was performed at 10 GCFs and 10 RDCFs in the Netherlands.

PARTICIPANTS

30 subjects from GCFs and 23 subjects from RDCFs, aged 65 years or over, were included in the study. Subjects from GCFs were mostly married males who were aged younger than the subjects from RDCFs who were mostly widowed females.

MEASUREMENTS

Dietary intake of the subjects was observed and/or recorded both at home and during their time at the day care facility.

RESULTS

In the GCF group, average total energy intake was significantly higher than in the RDCF group (8.8 MJ/d vs. 7.2 MJ/d). Also total carbohydrates and protein intakes were higher in the GCF group than in the RDCF group (with 257 g/d vs. 204 g/d, and 76 g/d vs. 65 g/d respectively). In addition, average total fluid intake was significantly higher in the GCF group than in the RDCF group (2577 g/d vs. 1973 g/d). Multiple linear regression analyses revealed that after taking possible confounders into account, day care type was still significantly related to the intake of energy, carbohydrates and fluids.

CONCLUSION

This study suggests beneficial effects of this new type of day care on dietary intake by community-dwelling older people with dementia.

Towards an integral conceptual model of frailty

OBJECTIVES

Most conceptual and operational definitions of frailty place heavy emphasis on the physical problems encountered by older people. The accompanying models are based largely on a medical model. An integral approach is almost never adopted. This study aims to develop both an integral operational definition of frailty and an integral conceptual model of frailty.

DESIGN

In order to achieve these aims, a thorough literature search was performed on components of operational definitions and models of frailty. In addition, experts (N=17) were consulted during two expert meetings.

RESULTS

There was consensus among the experts on the inclusion of the following components in the operational definition of frailty: strength, balance, nutrition, endurance, mobility, physical activity and cognition. Some respondents indicated that they would wish to add components from the psychological or social domain. Supported by results from the literature search, a new integral operational definition of frailty was developed. This operational definition lies at the heart of an integral conceptual working model of frailty. This model expresses the relationships between three domains of frailty, adverse outcomes such as disability and the determinants.

CONCLUSION

The model should be able to serve as a basis for further scientific research on frailty. The model also provides a framework for the development of a measurement instrument which can be used for the identification of frail elderly persons.

Definition of infection in chronic wounds by Dutch nursing home physicians

This study investigated the number and type of chronic wounds actually treated by Dutch nursing home physicians (NHPs). It was also the goal to know how many of the treated chronic wounds they considered infected. The NHPs were asked to choose and rank their top five out of several provided criteria for chronic wound infection. After this, the ranking was compared with the choices an international multidisciplinary Delphi group of wound experts made in 2005. A cross-sectional descriptive survey was conducted using the information from a self-reported questionnaire in a representative sample of Dutch NHPs. About 361 NHPs (25%) were sent a questionnaire. Of the 361 physicians, 139 (38.5%) filled in and returned the questionnaire of which 121 were valid. Of the NHPs, 73.5% actually treated at least one chronic pressure ulcers (PU), whereas 26.5% did not treat any. Of the responding NHPs,31.6 % treated at least one, but never more than two chronic post surgical wounds , whereas 68.4% of the NHPs treated none [corrected]. Chronic venous leg ulcers, arterial ulcers and diabetic ulcers scored infrequently and less than the other two sorts of chronic wounds. Of the Dutch NHPs, 53% considered that none of the PU infected. The other chronic wounds were judged far less frequently to be infected. Dutch NHPs appeared to use more 'traditional' criteria such as 'puss/abscess' and 'malodour' to identify infection and did not change their criteria by wound type. According to this study, NHPs do not frequently see many chronic wounds. The most frequent type of wounds treated was PU. For NHPs, the identification of infection of all types of chronic wounds is difficult. The use of criteria that is not in line with consensus documents may lead to ineffective treatment and even seriously damage patients: the clinical identification of infection is still dependent on experts' opinion. Further research on triggers for the suspicion of wound infection and the development of an evidence-based guideline is necessary.